Provider Demographics
NPI:1932109212
Name:ROTH, JEFFREY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 S FORT APACHE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-6737
Mailing Address - Country:US
Mailing Address - Phone:702-450-0777
Mailing Address - Fax:702-459-7701
Practice Address - Street 1:6140 S FORT APACHE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-6737
Practice Address - Country:US
Practice Address - Phone:702-450-0777
Practice Address - Fax:702-459-7701
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7663208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503381Medicaid
NVH37732Medicare UPIN
NV39398Medicare ID - Type Unspecified